By Amina Merchant
Monday, October 12, 2009
Amid all the debate over health-care reform, I find myself conflicted. I'm pleased because reform is vital; the U.S. health-care system does a disservice to many. Yet my experiences in medical school and residency have opened my eyes to the abuse that hospitals endure from patients taking advantage of the system. Both patients and hospitals need help.
Even if everyone in the United States had access to health care, health benefits would be optimized only if basic needs such as food and shelter are also met. I thought about this a lot last winter while working at medical centers on Chicago's West Side. At night, emergency rooms fill with healthy homeless patients in search of a warm bed and a good meal. Instead of seeking refuge in a shelter, where security and privacy are compromised, many homeless prefer a private room with a nurse to attend to them.
"I am suicidal with a plan," they say. People know that that phrase is a key to the psychiatric ward. After it is uttered, the hospital is obliged to house them overnight -- provide them a warm bed with a blanket and healthy meals. What would cost someone perhaps a hundred dollars in a basic hotel ends up costing taxpayers thousands -- because the hospital must provide not only a bed and food but staffing for its emergency room, a psychiatric consultation, one-to-one observation and monitoring of vital signs. The cost to the patient? A few hours in a heated waiting room.
This scenario plays out in hospitals across the country. Emergency rooms provide the only free point of access to various social services and so are targeted by not only the homeless but also victims of domestic abuse and drug addicts. Doctors and nurses trained to respond to matters of life and death find themselves confronting myriad non-acute social issues. The University of Chicago Medical Center determined this year that 40 percent of the 80,000 ER patients it admits annually did not require acute care. Emergency rooms are burdened with patients who come in for medication refills, routine vaccinations and other issues, in addition to those who do require immediate attention.
While working in a Chicago hospital as a medical student, I was once chased by a knife-wielding patient who claimed to have homicidal thoughts; with this display, he knew he could not be discharged. The man was homeless, and the situation was largely that he did not wish to live in a shelter or burden his family or friends. I have seen people refuse to leave the hospital because they do not want to pay the bus fare to go home. Still other patients are practically permanent residents at county hospitals. While some states provide poor U.S. citizens with social services such as nursing-home placement, some foreigners lean on county systems when their countries of origin do not take responsibility for their health care. Each day of this nonsense costs thousands of dollars per patient, billed to counties that are scrambling for funds.
The United States spends significantly more for health care than other industrialized nations, yet outcomes remain tragically worse by comparison. Expanding access to care may improve statistics, but responsible reform of the U.S. health-care system must include the capacity and funding of social services. If health care is made available to all Americans, care providers will be exploited, and costs will skyrocket, with hospital services a right but food and shelter remaining privileges. Already, hospitals are burdened with patients who are medically cleared but have nowhere to go. Thousands of dollars and work hours are wasted on patients each day just to arrange social services, whose cost to administer in an acute-care facility is more than it would be in other contexts and which siphon off funding from medical services.
Physicians are trained to practice medicine, and health-care reform ought to help them do that. Washington must take a comprehensive approach to reform. As Congress debates the costs of future care, lawmakers cannot forget that social services remain vital to cost control and effectiveness. Homelessness, unemployment and poverty have a serious effect on our health-care system. If these issues are not addressed with the same vigor, hospitals and doctors will continue to be stretched to administer services they are ill equipped to provide.
Amina Merchant is completing her general surgery residency in Chicago. She recently completed a Fulbright scholarship as an honorary research fellow at the London School of Hygiene and Tropical Medicine.